Mildly pruritic palmar rash

After taking azithromycin and prednisone for lower respiratory symptoms, this patient developed a rash. The way it spread provided a diagnostic clue.

An unusual oral chronic graft-versus-host disease-like syndrome following a liver transplant

BACKGROUND

Giving the immunosuppressive drug tacrolimus (FK506) to liver transplant patients has helped to considerably reduce oral side effects such as gingival hyperplasia. Patients taking cyclosporin who suffer from gingival hyperplasia are often switched to tacrolimus.

METHODS

We present here a pediatric liver transplantation case study. The patient has been followed for 5.5 years. She developed oral lesions that resulted in the immunosuppressive therapy being changed from tacrolimus to cyclosporin. In clinical terms, the atypical pathology consisted of hyperpigmented patches on the gingival margin, the internal surfaces of the cheeks, and the intraoral surfaces of the lips. When located on the lips, the hyperpigmented patches were associated with pruriginous and edematous lesions.

RESULTS

Optical and electronic microscopic examinations of a gingival tissue sample revealed the presence of melanin incontinence and lichenoid lesions with degenerated keratinocytes and a mild infiltrate of lymphocytes. This points to a chronic graft-versus-host disease (cGvHD)-like syndrome linked to tacrolimus. This diagnosis was given further credence by improvement in the lesions following the switch to cyclosporin.

CONCLUSION

To our knowledge, this is the first reported case of tacrolimus-associated chronic GvHD-like syndrome occurring in the oral mucosa.

[Contraception by subcutaneous Norplant implants. 300 cases]

It is a prospective study for the evaluation of the efficiency and the acceptability of Norplant contraceptive subdermal implants within the Senegalese female population. Three hundred women were selected on the basis of precise criteria between December 1986 and July 1991. Every patient included in the study signed a form of voluntary consent with the agreement of the consort, and was bound to come to control examinations until the removal of the implants. The insertion was made under local anaesthesia between the 1st and the 7th day of the cycle, or starting from the 6th week of post-partum in the other cases. The average age of patients was 32, and the average parity four children. 50 percent of women did not want any other children. The average insertion time is 4.8 minutes. The analysis of side-effects on 248 regularly followed women mostly reveals menstrual troubles like amenorrhea, spottings, menorrhagia. The fitful local prurigo was noted in 35 cases, and accidental pregnancy in 4 cases. The removal of implants within the first six months was made on 11 women (4.4%). As such, the Norplant implants constitutes a highly efficient method, well tolerated by Senegalese women.

[Septicemia due to methicillin-resistant Staphylococcus aureus from chronic prurigo in an elderly woman]

An 80-year-old woman being treated with anti-hypertensive drugs developed eruption and itching of the skin. High fever and lymph node enlargement subsequently developed in spite of discontinuing all antihypertensive drugs, and she was admitted to our hospital. At the initial examination, multiple papules were noted over the entire body, and the skin showed thickening and lichenification with scratch marks. There was also generalized enlargement of the superficial lymph nodes. From these findings, her condition was diagnosed as chronic prurigo due to drug allergy. Laboratory tests showed inflammatory findings, anemia and a high serum level of IgE. Analysis of the surface marker of peripheral lymphocytes revealed no abnormalities. Bacteriologic cultures of blood revealed methicillin-resistant Staphylococcus aureus (MRSA). Histologic examination of the lymph nodes revealed chronic reactive lymphadenitis with a follicular pattern. She was strongly suspected of having MRSA septicemia, and so combination chemotherapy with vancomycin, minocycline and cefoperazone/sulbactam was started. However, 1 month after initiation of chemotherapy, the low-grade fever, eruption and moderate inflammatory findings persisted, and culture of the eruptions revealed MRSA. The prurigo was therefore considered to be the source of the septicemia, and daily application of diflucortolone ointment containing 3% acetic acid was started. Thereafter, the clinical and laboratory findings showed a rapid improvement. MRSA infections usually occur in compromised patients who are receiving antibiotics during prolonged hospitalization. The present case, who did not have any underlying disease, indicates that old-age is also an important factor for the development of MRSA septicemia.